Infertility Causes by mikesanye


									  BioEthics                        2008
Bahe & Smith

               Not Making Babies
  BioEthics                                              2008
Bahe & Smith

               The Pain of Infertility

          The Introduction to “18 Ways to Make A Baby”
            BioEthics                                                                                     2008
          Bahe & Smith

                                The Pain of Infertility
              • Personal Story
                from Redbook

Not everyone has the goal of becoming a parent, but for those who do, being unable to conceive a
child is an exquisitely painful reality.
Many of us spend a portion of our lives attempting to avoid unplanned pregnancies, and assume that
once we are ready to conceive, it will happen with little difficulty.
We tend to think that shifting gears from preventing pregnancy to planning conception and childbirth
will proceed in a relatively smooth and orderly fashion.
A failure to conceive, then, is a major life stressor, which can wreak havoc on otherwise well-adjusted
Even in today's society, we tend to assume that individuals in committed relationships have the goal
of procreation.
Woman are often identified with their ability to give birth.
Both men and women are supposed to pass on their genetic and generational legacies.
Failure by either party to "fulfill their end of the bargain" can be devastating, humiliating, and
emotionally destructive.
The continuing taboo against discussing the subject of infertility compounds these reactions.
Even though tremendous strides have been made in treating this relatively common condition,
infertility is typically not openly discussed.
                BioEthics                                                                              2008
              Bahe & Smith

                                      Medical Definition


                PREGNANCY PROBLEMS:

Inability to conceive a child after a year of frequent intercourse without the use of contraceptives

Conception will occur but takes longer than usual

Pregnancy Problems: chromosomal abnormalities, fetal death, premature birth, low-birth-weight babies
  BioEthics                                      2008
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                 Whose “Fault”?

    •   30-40% Male
    •   30-40% Female
    •   20% Both
    •   10% ?????

        1 in 6 Couples have trouble conceiving
            BioEthics                                                                                      2008
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                            Normal Sperm Numbers

             •   Normal number of sperm?
             •   Volume of semen?
             •   Number per release?
             •   % Alive?
             •   % Normal Shape and Form?
             •   % Swimming forward?

             “Over the past 50 years, sperm counts around the world have fallen
             from an average of 113 million sperm per ml to between 66 and 76
             million.” From BBC’s Science and Nature website

From the WHO:

 Normal sperm count, as defined by the World Health Organization, is characterized by:

The concentration of spermatozoa should be at least 20 million per ml.
The total volume of semen should be at least 2ml.
The total number of spermatozoa in the ejaculate should be at least 40 million.
At least 75 per cent of the spermatozoa should be alive (it is normal for up to 25 per cent to be dead).
At least 30 per cent of the spermatozoa should be of normal shape and form
. At least 25 per cent of the spermatozoa should be swimming with rapid forward movement.
At least 50 per cent of the spermatozoa should be swimming forward, even if only sluggishly.
            BioEthics                                  2008
          Bahe & Smith

                                    Grading Sperms
              • Grade A: swim forward fast
                in a straight line.

              • Grade B: swim forward,
                curved or crooked line, or

              • Grade C: move their tails,
                but do not move forward.

              • Grade D: do not move at all.

                  From The World Health Organization

Sperm of grade c and d are considered poor.
            BioEthics                                                                                                2008
          Bahe & Smith

                                        Causes - Male
             • Britian’s Great Sperm Race

             ITV1 has enlisted a team of Portsmouth pub footballers for an experiment to
             boost their sperm counts [Spring 2008]. For the Great Sperm Challenge,
             the team aged from early 20s to mid-30s swapped pints of lager and fast
             food for a healthy semen-enriching diet for three months. From ITV1’s website

With male fertility rates plummeting in Britain over the past 50 years and with one in six couples having problems
conceiving, ITV1 has enlisted a team of Portsmouth pub footballers for an experiment to boost their sperm
counts.For the Great Sperm Challenge, the team aged from early 20s to mid-30s swapped pints of lager and fast food
for a healthy semen-enriching diet for three months. (May 2008)

I have not yet found the results which were aired in June 2008
            BioEthics                              2008
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                               Hormone Imbalance


Briefly go over the normal hormone pathway

Solution: Hormone injections
            BioEthics                                                                                                  2008
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                              Immune System Attack

                                                            A Case of Autoimmunity


Antisperm Antibodies. In many cases in which vasovasostomy fails, the reversal procedure reopens the tubes but
fertility is impaired because of a process called autoimmunity. With this condition, important immune factors called
antibodies attack the body's own cells, mistaking them for antigens (any foreign microinvader that the immune
system perceives as a threat).In the case of vasectomy, the autoantibodies attack the sperm, and so are called
antisperm antibodies. Such antibodies develop when sperm continue to be produced after vasectomy, but, instead of
being confined to the reproductive passages, they leak out into the body. Once out of their natural habitat, the
immune system perceives them as foreign invaders and develops antibodies to attack them.

Solution: Injection of immune suppression drugs OR Sperm Washing
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                 Sperm Washing

  • WHY WASH SPERM?, to remove antibodies, to decrease HIV,
    increase survival when frozen
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                                           Varicose Vein
                • Varicoceles

                 Extra blood = Extra Hot!!


Somewhat common: 10% of men

In 20s to 30s

No symptoms, harmless

May cause pain or atrophy of the testicles or fertility problems- VERY HOT TESTES!!!

Normally, blood flows to the testicles through an artery, and flows out via a network of tiny veins that drain into a long
vein that goes up through the abdomen. The direction of blood flow in this vein should always be up, toward the
heart. A series of one-way valves in the vein prevent the reverse flow of blood back to the testicles.
These one-way valves sometimes fail. The reverse flow of blood stretches and enlarges the tiny veins around the
testicle to cause a varicocele, a tangled network of blood vessels, or varicose vein

Diagnosis: lumpy appearance, or X-rays or specialized ultrasounds to measure blood flow

Solution: Surgical removal
            BioEthics                                                                  2008
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                                   Drugs & Chemicals

                  Solution                         Steroids              Antibiotics

Cocaine, marijuana, lead, arsenic, sterioid, antibiotics, chemotherapy

Solution: Stop Taking them
            BioEthics                                                                                  2008
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                               The Prostrate Gland

              • Solution?

The prostate gland is one of the fluid producing organs in the male body. Its function is to produce
seminal fluid (semen) that nourishes and transports the male gamete (sperm) through the female
reproductive tract. Thus its proper and successful functioning is a key factor in male fertility.

Needed for semen solutions, transport,

An enlarged prostrate can block transport of semen

Solution: May be surgery male
             BioEthics                                                                                                    2008
           Bahe & Smith

                                       Testicular Injury

               • Solution?

Can implant artificial testes but they won’t make sperm.

Testicular cancer may necessitate testes removal

esticular torsion occurs when a testicle rotates on the spermatic cord, which provides blood flow to the testicle. This
rotation cuts off the flow of blood and causes sudden, often severe pain and swelling. Testicular torsion is most
common in males under 25, but it can occur at any age, including in newborns and infants.Testicular torsion requires
emergency treatment. If it's treated within a few hours, the testicle can usually be saved. But waiting longer can
cause permanent damage and may affect the ability to father children. When blood flow has been cut off for more
than 12 hours, a testicle may become so badly damaged it has to be removed.Although doctors can sometimes
untwist a testicle by pushing on the outside of the scrotum, surgery is needed to prevent testicular torsion from

Solution? There may not be one or surgery.
            BioEthics                                                                                                  2008
          Bahe & Smith

                               Undescended Testicle

               • Solution?

Can implant artificial testes but they won’t make sperm.

Testicular cancer may necessitate testes removal

ryptorchidism is the most common abnormality of the male genital tract, affecting 3 5% of full-term male infants and
30 32% of premature male infants. In most cases, the condition resolves during the first few months after delivery;
only 0.8% of infants over three months of age still have undescended testicles. Because of the potentially serious
consequences of cryptorchidism, however, doctors do not advise watchful waiting once the child is over six months
old. Undescended testicles rarely come down into the scrotum of their own accord after that age.

             BioEthics                                                                                                      2008
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                                    Y Chromosome Deletion


There is only one Y chromosome; nothing to cover it up

Compare to two X’s.

Male factor infertility accounts for about half the cases of couple infertility. In more than 60 % of cases the origin of
reduced testicular function is unknown but they may have an unidentified genetic anomaly. (BioScience)

Large Deletions: no sperm made at all
Small Deleltions: only make a small amount of sperm

 The diagnosis of Y chromosome infertility is suspected in otherwise healthy males with azoospermia
or oligozoospermia and/or abnormal sperm morphology/motility for whom other causes of infertility
have been eliminated. Routine cytogenetic testing reveals chromosome abnormalities in 5%-10% of
these men. Molecular testing reveals microdeletions of the long arm of the Y chromosome in another
5%-10% of these males. Such molecular genetic testing is available clinically.
  BioEthics                           2008
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                  Genetic Mutations
  • Mutant
  • Mutant
  • Mutant genes to
    regulate sperm
  • Mutatn genes to
    regulate motility
            BioEthics                                                                                        2008
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                                 Low Sperm Counts

If a man has low sperm counts, but normal sperm, he can donate his own sperm, keep several samples in cold
storage, and pool together
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               Tight Underwear
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                                    Low Sperm Motility

Can’t move, can’t get to egg

Missing or misshapen heads; broken tails, more than one flagella

Solution: if tails can do intracytoplasmic sperm injection

If heads, no solution
            BioEthics                                                2008
          Bahe & Smith

                        White Blood Cells in Semen
              • WBC -->
              • Toxins -->
              • Bind to sperm
                membrane -->
              • Destroy enzymes to
                make ATP -->
              • No energy -->
              • No movement -->
              • Low fertility


Solution: Antioxidants are being researched as possible preventive
            BioEthics                                2008
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                                Abnormal Apoptosis

Apoptosis normally kills abnormally shaped sperm
            BioEthics                             2008
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                   Female Causes - Normal cycle

Briefly review normal hormone pathways.
           BioEthics                                                                                       2008
         Bahe & Smith

                        Predict Ovulation - Saliva

Ovulite operates on the principle that saliva when you are on the verge of ovulating - forms a ferning
pattern when it dries. These fern-like patterns (which appear like frost on a windowpane) are easily
observable through the Ovulite ocular lens which is capable of a 40X magnification. By observing
changes in your saliva patterns, you can predict ovulation -with 98% accuracy. "Ferning" patterns
(#3) indicate ovulation and peak fertility. Ovulite is FDA-registered and very easy to use. Ovulite
consists of a small, cylindrical container about the size of a lipstick tube, a high-quality focalizable
eyepiece, and a small slide where the saliva sample is placed and illuminated with an LED light when
a button is pressed. Advantages of Ovulite include: Access to a toll-free helpline 24 hours per day, 7
days per week. The only FDA-Registered Ferning Scope on the market! An unconditional money-
back guarantee! A 98% accuracy! Easy-to-use with virtually no learning curve! Unlimited testing
completely re-usable! Comes with a free carrying case and a detailed instruction book.
  BioEthics                            2008
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     Predict Ovulation - Temperature
  • Basal Body
  • .5 - 1 oF rise
             BioEthics                                                                                                       2008
           Bahe & Smith

                Predict Ovulation - Mucus Patterns

Cervical Mucus Method
The cervical mucus method is based on another hormonal change that occurs during the menstrual cycle. The
cycle begins with menstruation. During menstruation, the flow disguises the mucus signs. The menstrual period is
usually followed by a few days when no mucus is present these are dry days.              The dry days are nonfertile days.
  As an egg starts to ripen, mucus increases in the vagina and appears at the vaginal opening. It is generally yellow
or white, and it is cloudy and sticky, or tacky. The greatest amount of cervical mucus usually occurs immediately
before ovulation during the slippery days. The mucus takes on a clear and slippery quality that resembles raw egg
whites. It also will stretch between your fingers. Fertilization is most likely to occur during this phase. You would
abstain from vaginal intercourse or use a barrier contraceptive during this time to avoid pregnancy. After about four
days of slippery days , the mucus may become cloudy and tacky, and decrease in amount. This is the return to
nonfertile days. The fewest pregnancies occur when intercourse takes place only on the dry days after ovulation. naturalfamilyplanning.html
            BioEthics                                                        2008
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                                 Predict Ovulation
                               - Measure Hormones

Measures the LH surge at ovulation. Can be measured just before ovulation.

Cost: $2-$3 per test
             BioEthics                                                                                        2008
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                       Hormone Imbalance - Tumors

               • Solution


Ovary or pituitary or thyroid tumor
If the ovaries produce too much androgen (hormones such as testosterone) a woman may develop
male characteristics. This ovarian imbalance can be caused by tumors in the ovaries or adrenal
glands, or polycystic ovarian disease. Virilization may include growth of excess body and facial hair,
amenorrhea (loss of menstrual period) and changes in body contour.

In PolyCystic Ovarian Syndrome, increased androgen production produces high LH levels and low FSH
levels, so that follicles are prevented from producing a mature egg. Without egg production, the
follicles swell with fluid and form into cysts. Every time an egg is trapped within the follicle, another
cyst forms, so the ovary swells, sometimes reaching the size of a grapefruit. Without ovulation,
progesterone is no longer produced, whereas estrogen levels remain normal. reports/000101_2.htm

Doctors in Ohio have removed a 66-pound tumor from a woman who said she now feels as if a long pregnancy is
over. (2004)

Solution: Surgery
            BioEthics                                                                                              2008
          Bahe & Smith

                       Hormone Imbalance - Drugs

              • Solution

Cortisone increases male hormone output, decreases female hormone output, causes oversecretion of polactin (milk
production and suppresses ovualtion

Solution: Stop taking cortisone

Could also be caused by eating disorders and starvation diets
               BioEthics                                                                                            2008
             Bahe & Smith

                   Treatment: Fertility Drugs - Oral

Oral drugs
Modest results
Stimualte release of FSH and LH
Rates of pregnancy: 35-40% after 4-6 cycles

Therapy beyond 6 cycles is not useful

It also thickens the cervical mucus and thins the llining of the uterus which are two reasons why some do not get
pregnant with this medication.

Multiple pregnancy rate here is low, 7-10%, mostly twins
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          Bahe & Smith

                         Treatment: Fertility Drugs -

Some have FSH and LH; some only LH

Expensive - $500 - $1000/month

Need 7 - 10 days worth of shots per month

Prone to multiple births (15-20%) due to superovulation

Pregnanacy rates of 50% (cumulative)
Produces better quality eggs and does not thin the uterine lining
            BioEthics                                2008
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                           Absent/ Missing Ovaries

Birth Defect


Missing ovaries can no longer make eggs!
            BioEthics                                                                                                2008
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                          Treatment - Moving Ovary

Ovary tissue first stored, frozen and reimplanted to a woman s arm, restoring her menstrual cycles, by team led by
Roger Gosden and Kutluk Oktay

A segment of ovary from a 30-year-old American woman, Margaret Lloyd-Hart, which had been
removed and frozen several years ago, was grafted back inside her in February by Dr Kutluk Oktay at
New York Methodist Hospital.

The grafts could be used to treat sterility caused by the onset of premature menopause and protect
fertility in patients undergoing cancer treatment
           BioEthics                                                                                    2008
         Bahe & Smith

                     Treatment - Freezing Ovary

BRUSSELS - A Belgian woman has given birth to the first baby born after an ovarian tissue transplant,
a medical advance that gives hope to young cancer patients whose fertility may be damaged by
chemotherapy.The baby, a healthy girl named Tamara, was born at 7:05 p.m. on Thursday in a
hospital in Brussels and weighed 8.2 lb. Her mother is Ouarda Touirat, 32, a hospital spokeswoman
said.The birth, announced by The Lancet medical journal, which is to publish the results of the
procedure Friday, marks the first time fertility has been restored to a woman after doctors cut out
and froze some of her ovarian tissue and transplanted it back into her body years later.
             BioEthics                                                                                                       2008
           Bahe & Smith

                      Treatment: Ovary Transplants

               • 2004

An Alabama woman gave birth this week to a baby girl after undergoing the first known successful ovary transplant
in the United States. Stephanie Yarber, 25, gave birth Monday night to a 7 pound, 15 ounce girl named Anna, said
her identical twin sister, Melanie Morgan. It was the sister who donated the ovarian tissue that made Yarber fertile.
"It's a wonderful thing," Morgan said Tuesday, characterizing the successful procedure as a "partnership with God,
my sister and me." Dr. Sherman Silber, an infertility specialist in St. Louis, performed the transplant in April 2004,
and Yarber became pregnant only five months later. Yarber became menopausal at age 14 and was unable to
become pregnant without medical help. She had tried in vitro fertilization twice, using eggs donated by her si ter, but
nothing worked until the ovary transplant. "It's seemed like a wild thing to do, but after 40 years of animal research, it
did exactly what we expected," Silber said. Silber said he has since performed the transplant surgery on two other
sets of identical twins. He said he believes more infertile women will now seek out the procedure. The child was born
at a hospital in Russellville, about 20 miles northwest of Montgomery. There have been similar procedures
performed outside the United States. In Belgium, an ovary was transplanted in September not from another woman,
but from the mother herself. Seven years beforehand, doctors removed and froze her ovarian tissue before she
underwent chemotherapy. They transplanted the tissue back into her body when she was cleared of cancer. And
more than a year ago, surgeons in China reported a successful whole ovary transplant between sisters.
             BioEthics                                                                                                      2008
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                      Treatment: Ovary Transplants

               • 2007

From The TimesAugust 2, 2007Ovary transplant success opens up new approach to restoring lost fertilityMark
Henderson, Science EditorThe first ovary transplant between women who are not identical twins has been performed
successfully in Belgium, offering a new route to fertility for women who lose it because of an early menopause or
medical treatment.Teresa Alvaro, who is now 37, has started to menstruate again and has produced two eggs that
have been fertilised with her husband s sperm after receiving grafts of ovary tissue donated by her sister, Sandra,
34.The revolutionary procedure, performed by Jacques Donnez, of the Catholic University of Louvain (Leuven), near
Brussels, has given Teresa fresh hope of children. She became infertile aged 20 because of treatment for a rare
blood disorder. It also opens a new approach to restoring the fertility and menstrual cycles of thousands of wome    n
who have suffered premature ovarian failure, usually as a result of chemotherapy for cancer or other diseases or an
early menopause.While a handful of ovary transplants have been conducted before, and at least one woman has
given birth after the operation, all these procedures have involved identical twins. As such twins share all their genes,
there is no risk of tissue rejection.
             BioEthics                                                                                                          2008
           Bahe & Smith

                              Blocked Fallopian Tubes

Can result in Ectopic pregnancy

Causes: birth defect, infection (pelvic inflammatory disease), endometriosis, IUDs, STDs

Treatment: surgery
Endometrium is the name given to the inside lining of the cavity of the uterus (the womb). But in a percentage of
women, patches of endometrium-like tissue are found elsewhere in the pelvis or abdomen on the ovaries, uterus,
bowel, bladder, ligaments (bands of tissue that hold the uterus in place) and in the Pouch of Douglas (the area
between the uterus and bowel).

Exactly why tissue that should normally be found in the uterus ends up at these other sites isn't known. One theory
says that fragments of endometrium somehow migrate up through the fallopian tubes and then out into the pelvis
through the space between the end of the fallopian tube and the ovary. Another says that the aberrant endometrium
is laid down during early foetal life.Despite the fact that they aren't in the uterus, the fragments of tissue still act like
uterine endometrium. They are influenced by the same sex hormones (oestrogen and progesterone) that cause the
uterine endometrium to thicken in the first half of the menstrual cycle, and (if there's no pregnancy), to break down
and bleed in the second half. But the unlike the endometrium in the uterus, which is passed through the cervix and
vagina as a menstrual period, the pelvic endometrium has nowhere to go and bleeds directly onto the surface of the
surrounding organs and tissues. This causes irritation which leads to inflammation, scarring and, sometimes, the
development of adhesions (abnormal fibrous tissue growth) between organs.As the disease progresses, these areas
of aberrant endometrium grow and they may eventually form cysts. These are usually small less than two or three
centimetres in diameter but can grow as large as ten or more centimetres. Cysts on the ovary are known as
'chocolate cysts' or endometriomas.Endometriosis is a common condition, affecting about ten per cent of Australian
women at some stage during their menstruating years. It can occur at any time between puberty and menopause. It's
more common in women who have few pregnancies or none, who have pregnancies later in life, who don't
breastfeed (or breastfeed for short periods) and/or have female relatives with the disease.
            BioEthics                                                                                             2008
          Bahe & Smith

                                      Uterine Fibroids

Uterine fibroids (also referred to as myoma, leiomyoma, leiomyomata, and fibromyoma) are benign
(non-cancerous) tumors that grow within the muscle tissue of the uterus. Between 20-50% of women
of childbearing age have uterine fibroids. While many women do not experience any problems,
symptoms can be severe enough to require treatment.Fibroids range in size from very small (coin
sized) to larger than a melon. A very large uterine fibroid can cause the uterus to expand to the size
of a six or seven-month pregnancy. There can either be one dominant fibroid or a cluster of many
small fibroids.

Many women who have uterine problems may have no problems getting pregnant, but they may have
difficulty in keeping the pregnancy as they tend to miscarry. Most women have no symptoms, some
women will have scanty periods, and if the woman has no uterus she will have no periods, (but
remember there are many causes of absent periods). Some patients may also complain of heavy
periods (due to fibroids).

305 of women have some fibroids

 Fibroids are growing large enough to cause pressure on other organs, such as the bladder. Fibroids are growing
rapidly Fibroids are causing abnormal bleeding Fibroids are causing problems with fertility

Endometriosis - Excessive growth of the lining
             BioEthics                                                                                   2008
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                                     Vaginal Secretions
               • Mucus

               • Very acidic or


Mucus - Unusually thick, sticy, can be caused by infections, traps sperm
Very acid or alkaline secretions can kill or weaken sperm

Too little mucus - sperm can enter

Treatments: rinse vagina with a buffered solution

Treat too little mucus with estrogens

Solution: Artificial Insemination to by-pass the mucus

The cervical mucus is a jelly-like substance produced by minute glands in the cervical canal. It
changes in consistency and composition with the menstrual cycle. Just before ovulation and under the
effect of the hormone estrogen it becomes very watery and copious to allow the sperm to swim
through it. After ovulation and under the effect of progesterone, the mucus becomes thick and sticky,
which render it impenetrable to the sperm. Once the sperm are in the mucus, they can stay there for
a few days. Thus the mucus acts as a sperm reservoir.Cervical mucus hostility is the inability of
sperm to penetrate the cervical mucus. The significance of cervical mucus hostility is disputable
among infertility specialists. Problems with cervical mucus usually cause no symptoms.

The mucus is too sticky and thick (and there is not enough of it to allow sperm to swim through). This
may be due to poor estrogen stimulation of the cervical glands (e.g. wrong timing of the test or lack
of ovulation) or poor functioning cervical glands due to infection or damage caused by surgery, as
may occur after cone biopsy.
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                  Egg lacks biochemical attractants

Solution: Artificial insemination
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               Maternal Age
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               Maternal Age
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         Maternal Age & Trisomy 21
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            BioEthics                                                                                         2008
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                                          Paternal Age

Men can father children no matter their age, but there is some decline.

Thenumber of sperm, motility of sperm and percent normal sperm all decease slightly.

Pregnancy rates decline, birth rates decline and miscarriage rates increase when the male is > 50 years old
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                                          Maternal Age

Quantty vs quality

As women age, the quality of their eggs deteriorates

As women age, the likelihood of miscarriage and chromosomal abnormalities increases

As women age, they are more likely to begin menopause
           BioEthics                                                                             2008
         Bahe & Smith

                             Antipserm antibodies

            • Solution

Antibodies produced by the immune system against sperm. It adversely affects sperm function by
inhibiting movement of sperm and fertilization. It can be present in males and females

Antibodies can be detected

Solution: Treatment with Steroids

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